Client Agreement

for Massage, Manual Lymphatic Drainage, and/or ABMNM® movement lessons. Please read, sign or initial and date where appropriate. This agreement remains valid throughout all treatment sessions, present and future. I understand that the information I provide on this form is confidential. The information collected is for treatment protocol, the therapist clinical analysis, and for office files. I understand that the massage/bodywork that I receive is provided for purposes of relaxation, for relief from muscular tension and associated pain, as well as to relieve limited range of motion. This is a therapeutic massage and/or lymphatic drainage session. If I experience any pain or discomfort during my session, I agree to immediately inform the therapist so that the pressure or technique employed may be adjusted to my comfort level. I understand that the therapies offered are NOT a substitute for medical care. I understand that the therapist does not diagnose or cure disease. Any information provided to me is educational in purpose and intent, and is not diagnostically prescriptive in nature. Because massage therapy may be contraindicated under certain health conditions, I affirm that I have disclosed all known health conditions and injuries, medication use, and allergies; and have honestly answered all questions asked for purposes od my care. I agree to keep the therapist updated if there are any changes in my health, pharmaceutical use and/or healthcare protocol. I agree that there shall be no liability on the therapist’s part, if I fail to do so.

I understand that the services I receive are strictly therapeutic, and non-sexual in intent or practice. I understand that I am financially responsible for my appointments, and that payments due at time of service, unless prior arrangements have been made. In order to avoid charges, I agree to provide 24 hour notice of cancellation. I understand the following Statement of Privacy Practices regarding my health care information: This practitioner does not file health insurance, so that limits the availability of information available to others. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. Without your directive, in writing, unless otherwise required by law, your healthcare information is protected. Also, I give my permission for the therapist/clinic to leave information for me at the front desk. I agree that the therapist/clinic may use my provided phone number(s) or email(s) or mailing address(es) to leave messages or send any verbal or written information to me, with my identity on such documents or recordings disclosed. If you do not agree to such disclosure, please write clearly what form of communication you request to be prohibited, as well as what form(s) you will allow. Honor respects your privacy, as mentioned above, and in treatment. For ABMNM® Movement Lessons you will remain fully clothed. Honor does her best to properly drape you in massage sessions.

Honor does not require the removal of clothes for your massage. Please undress to your level of comfort, realizing that sheets are used during the session to cover intimate areas and your overall body as much as treatment allows, i.e., if she is working on your upper torso and neck, your gluteals and legs are covered. Honor undrapes areas of the body as treatment requires, and can work through the sheets (though not as effectively) if you prefer. Please communicate your needs and preferences before and during your massage. Thank you.

Please note: Failure to show up for scheduled appointments may result in a no-show charge of $75.00 at the therapist’s discretion.